Provider Demographics
NPI:1437708120
Name:EDWARDS, PAMELA BETH
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:BETH
Last Name:EDWARDS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3401 E 30TH ST
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87402-8805
Mailing Address - Country:US
Mailing Address - Phone:505-599-8617
Mailing Address - Fax:855-290-2205
Practice Address - Street 1:5700 COLLEGE BLVD
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87402-1773
Practice Address - Country:US
Practice Address - Phone:505-599-8880
Practice Address - Fax:855-648-0620
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-05
Last Update Date:2019-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMM-057601041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchoolGroup - Single Specialty